Oesophageal cancer

Question 1

What is the most common type of cancer in the oesophagus?

Answer 1

Squamous (85%)

adenocarcinoma ~10%

Question 2

What are the risk factors for squamous cell carcinoma of the oesophagus?

Answer 2

• Strong association between cigarette + alcohol consumption and incidence
• High take of nitrosamines derived from nitrates used n food preservatives
• Low intake of both vitamin A and nicotinic acid
• Iron deficiency anaemia

Question 3

How does adenocarcinoma of the oesophagus arise?

Answer 3

Metaplastic change in the oesophageal mucosa following change in the oesophagus mucosa from squamous to columnar

Question 4

What are the risk factors for adenocarcinoma of the oesophagus?

Answer 4

• Reflux oesophagi’s
• Barrett’s oesophagus
• Achalasia
• Alcohol excess
• Smoking
• Nitrosamine exposure

Question 5

What investigations should be carried out when diagnosing oesophageal cancer?

Answer 5

• Barium swallow
• CXR
• Oesophagoscopy with biopsy/endoscopic US
• CT/MRI

Question 6

How does a patient with oesophageal cancer present?

Answer 6

1. Early ill-defined symptoms:
   - feeling that there is something stuck in the oesophagus
   - retrosternal discomfort
   - belching and dyspepsia
2. Progressive dysphagia:
   - most common and important presenting symptom
   - does not present until the diameter of the oesophagus is reduced by 2/3rds
   - trouble swallowing solids first followed by swallowing liquids
3. Weight loss:
   - dramatic decline with 10-15% loss in 4 weeks
4. Acute obstruction:
   - may occasionally be precipitated by a large food bolus in an asymptomatic patient

Question 7

What are the red flag symptoms for oesophageal cancer?

Answer 7

• Dysphagia
• Vomiting
• Anorexia and weight loss
• Symptoms of gastrointestinal-related blood loss

Question 8

How is oesophageal cancer treated?

Answer 8

1. Medical:
   - chemotherapy and radiotherapy can be used as neoadjuvants to surgery
   - cannot be cured by medical treatment alone, only used in palliation
2. Endoscopic:
   - in early cancers
   - submucosal resection or radio frequency ablation
   - also endoscopic laser treatment
3. Surgical:
   - resection of the tumour as long as there are no signs of distant metastasis
   - defect is bridged by mobilising the stomach up into the chest with anastomosis to the residual oesophagus or pharynx in the neck

Question 9

What role does palliative care play in oesophageal cancer?

Answer 9

• Most patients present with incurable disease and require palliation
• Dysphagia can be treated by endoluminal self-expanding metal stenting (SEMS) or external beam radiotherapy
• Surgery is rarely indicated for palliation
• Systemic chemotherapy if symptomatic (for metasases)